Brave Woman

Adventures of a future nurse-midwife

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Notes for When I'm a Preceptor

Posted by Lucille on March 26, 2016 at 4:35 PM

I know I will have a lot more experience working with preceptors before I'm ever in the position to be one, but in case some of my observations about what works well in promoting a good student-preceptor relationship are specific to working with students who are just starting out and haven't worked within student-preceptor relationships before, I wanted to get my thoughts so far written down. Here are some of the things preceptors have said or done in this first half of nursing school that were particularly helpful.

"Fill me in. What do you know, what are you learning, what will you not be doing today, and where do you want to go with all of this?" I was surprised by how many preceptors simply nodded when I was assigned to them and then went about their day as if I didn't exist, and it made me appreciate the preceptors who created this moment proactively, especially those who went beyond a basic introduction to show interest in my long term goals. Even if it is only a few seconds long, it is really important that an introduction happen at the start of the day, before you go in a patient room. Ideally, the student will initiate it, but students can be nervous and preceptors can be intimidating and the most important thing is that regardless of who initiates it, this exchange happens. This is because knowing your student's scope effects patient safety. For example, one preceptor that I had was obviously in a rush and I struggled to find a moment in the midst of handoff to insert my introduction, one of the pieces of which was that I was not permitted to mobilize patients by myself. We got a patient up and then paused at a bench in the hallway for the patient to rest, when the nurse got a Vocera message calling her to another patient room. She left immediately, leaving me and the patient stranded, because she assumed that finishing the walk and getting the patient back to their room would be well within my scope. It's challenging for preceptors to keep track of what their students can and can't do when our scope changes every week (I mean, I can barely keep track, and they may be working with several cohorts of students from several different schools). I worked to be more assertive about introducing myself after this incident, but it can still be challenging, and ultimately making sure that this exchange happens is a shared responsibility.

"Tell me about your experience with (blank)." This is in contrast to, "Do you know how to (blank)," "Have you covered (blank)," and "How many (blank) have you done?" At least for me and my learning style, performing a task/intervention in class and performing it with a patient feels like two different things entirely, and I could practice it a million times on the mannequin and I would still go blank the first time I tried to do it with a real patient. Furthermore, I've found that my improvement in skills is not at all linear. I've had the opportunity to insert a lot of catheters so far, more than most students I've talked to, and even got the nickname 'catheter queen' from one of my clinical groups. With that said, the more recent catheter insertions I did were the most embarrassing. My preceptor asked how many I had done before and I answered that I'd done more than a dozen. I suddenly felt pressure to do things perfectly and got a lot more nervous, at the same time that my preceptor assumed that I wouldn't need help and positioned herself to offer distraction to the patient instead. Things went downhill from there. The best experiences with practicing new skills that I've had so far came when preceptors instead asked, "Tell me about your experience with (blank)," because it elicited a lot more information from me, acknowledged that the same task can be different with different patients or under different circumstances, and gave me permission to share that I was nervous (even if I'd performed the skill successfully before). For example, for catheter insertion, this question might elicit information about whether the previous catheter insertions I'd done were on men or women, whether the men had benign prostate hyperplasia, whether the patients were numb or had full sensation, whether any infections were present in the immediate area, etc. This information is much more useful to the preceptor than a number would be, and it helps build rapport between the preceptor and student on top of it, because as a student I felt like the preceptor had a good sense of my needs and a genuine interest in supporting my learning.

"You're practicing learning while nervous." This is in contrast to, "You'll feel more confident next time." Because what if the student doesn't feel more confident next time? I'm more than halfway through nursing school, and the list of nursing skills that don't make me nervous is still a blank page. One of the best things a preceptor said to me this year was "Great job learning while nervous. That's a really useful skill, and one you'll never stop using!" A reminder that I don't have to be perfect tomorrow, or even 20 years into my career, really helped normalize my nervousness and put me more at ease.

Specific praise (of literally anything you can think of) is so valuable. I do not know a single nursing student who isn't their own worst critic. Everyone loves a confidence boost, it builds rapport, and your student will remember it for weeks. Perhaps more importantly, a lot of the time I really don't know what I'm doing well, and reinforcing positive behaviors with praise is a great learning tool. I imagine that part of the challenge for preceptors is thinking to compliment behaviors that are so routine you no longer think about them. Praising good nursing behaviors early and often also makes it easier to give (and for the student to receive) constructive criticism later on.

"What did you see me do?" This is really useful when a student is shadowing you or just watched you do something they are learning or might not have seen before. Repeating what they saw helps commit it to memory, and it gives you a chance to add things they might not have noticed, or explain your reasoning behind doing it a certain way.

"Let's talk about what you're going to do when we get in the room." This is a great defense against students going blank when faced with a patient. It also creates room for the preceptor to give more focus to effective patient distraction, or to observing the student and giving more specific feedback.

"Let's talk about what you just did. What did you think went well and how could it have been better?" I like this phrasing because it gets into the specifics rather than asking for an overall impression, and it encourages reflection on the part of the student before any additional feedback is given.

Narrate your clinical judgment out loud. This is a difficult skill, but it is one of the most helpful learning tools, even when the clinical judgment is not responding to something critical but just looking over your patient assignments and making a rough plan for the day. The step between getting information and implementing a response is often invisible, and getting a peek into your thinking is probably the single most educational thing I've experienced so far in clinicals.

Introduce your student, and introduce them as your student, not as your 'special friend'. I have no idea why nurses keep introducing me as their special friend but it always reminds me of creepy characters in horror movies introducing the doll/puppet/mannequin that will later come to life and eat people. If you're worried that the patient will object to having a student, follow it up with a joke about a two-for-the-price-of-one nursing special, but do not try to hide the fact that I'm a student. It feels icky, it's not informed consent, it doesn't fool the patient, and it undermines the rapport I haven't even had a chance to build yet.

Keep your ears open for learning opportunities elsewhere on the floor. I love it when nurses say, "Hey, I heard there's going to be an XYZ happening, do you want me to see if it would be okay for you to go and watch?" Not only do I get a great learning opportunity, but everyone in my clinical group will learn about it from me later, I get to see advocacy in action, and it shows me my nurse wants me to have the chance to learn as much as possible. Winning all around.

Understand that your student will be anxious and exhausted. Just being in such a high-intensity learning mode is exhausting, even when I don't appear to actually be doing anything. When I'm hanging out at the nursing station, I'm watching and absorbing everything around me. Where do the nurses sit? How much time do they spend there? Where are the other healthcare professionals? How much do they talk across professions, and how much of that is work vs. social? What are people talking about? How do they talk about it? What resources are they accessing? What are they wearing to work? Who are the housekeepers and what are they doing? What are they happy about and what's a source of frustration? How do the nurses interact with each other? With the charge nurse? With the CNAs? What's that alarm and how did people respond to it? How is this similar or different from the other units I've been on? After a few hours of this, without even doing anything or asking any questions, I'm ready for a break, and that's without accounting for the fact that I was probably exhausted from all my other classes before I got to clinicals and that most of my time is not spent at the nursing station, but in patient rooms doing even more rapid/intense learning. This is just to say that if your student is yawning, spacey, messing up, or needing information repeated several times, they will really appreciate being offered the benefit of the doubt.

Model self care. I can't even imagine taking care of four patients at this point, much less having four patients and a student. Sometimes you will be exhausted, anxious, and frustrated too. Please remember that you're allowed to be. Letting us into your struggle can be a wonderful teaching moment if you show us how you cope with the demands of your work. Furthermore, model the everyday routines that are evidence-based for building resilience, not just coping. Take lunch. Take your breaks. Drink that cup of coffee you made. Even if you can't make it happen every time, show us that self care is something worth carving out time for in the real world, and you will help usher in a resilient new generation of nurses who are confident in their worth and the value of the work they do.

I have been tremendously grateful for the preceptors I've gotten to work with so far. In the deluge of new experiences that is every day at clinical, it's challenging to find moments to adequately express my gratitude. When I have found opportunities to let preceptors know how much their mentorship and teaching means to me, all of them (but especially the most exceptional preceptors) seem to grossly underestimate their own skills and impact. So, for any preceptors reading this, please know that you are appreciated. You are so, so appreciated, even when your students struggle to step back from the flood of new experiences long enough to let you know.

I'm curious to hear what other students would change or add to this, and if any preceptors have thoughts about the most helpful things students can do.

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Sometimes I have the privilege of being a part of intimate, powerful moments in other people’s lives. I cannot and would not share these stories, because they are not mine to tell. However, they touch my life and become part of my own story. When I share these moments here, you can trust that I have not broken anyone’s confidentiality. The characters are invented. They are not real, but could be. I take creative license to communicate the essence of my experience while respecting the privacy of others.